Perineal descent is defined as the descent of the anal margin below the ischial tuberosities and is commonly associated with constipation and pelvic organ prolapse. While minimally invasive approaches are well established for POP, the optimal management of PD remains unclear. We present a robotic-assisted technique that addresses both conditions in a single procedure: the Integral Perineal Sacrocolpopexy.

We present the case of a 73-year-old woman with a history of  vaginal hysterectomy due to uterine fibroids. She presented to our clinic with mild urgency urinary incontinence and symptomatic pelvic organ prolapse. Physical examination and magnetic resonance imaging confirmed the presence of a cystocele, vaginal vault prolapse and perineal descent. 
A robotic-assisted laparoscopic approach using the da Vinci system was performed. 
The patient was placed in a 30° Trendelenburg position, and four robotic ports + a laparoscopic port were inserted. A macroporous monofilament polypropylene mesh was used. The procedure included fixation of the sigmoid colon, dissection of the sacral promontory, and development of the rectovaginal, vesicovaginal and paravesical spaces. The posterior mesh was fixed to the levator ani muscle, uterosacral ligaments, and vagina. The anterior mesh was positioned through a created tunnel and secured to the endopelvic fascia and vagina. Both meshes were anchored to the sacral promontory and reperitonealized.

The postoperative course was uneventful, and the patient was discharged on postoperative day one. At 6-month follow-up, the patient reported urgency without urinary incontinence, similar to her preoperative symptoms. There was no evidence of prolapse recurrence, perineal descent, mesh erosion, constipation, or pain. This technique has been performed in 15 patients with combined perineal descent and pelvic organ prolapse, achieving a 100% success rate at 12 months, without complications or chronic pain. Mean operative time was 145 minutes and average hospital stay was 2 days.

Robotic-assisted Integral Perineal Sacrocolpopexy is a safe and effective technique that provides support to the perineum and pelvic organs. It represents a promising surgical option for patients with combined pelvic organ prolapse and perineal descent.